Primary Care Case Management (PCCM)

History

PCCM as an approach to Medicaid was enabled by an amendment to Title XIX of the Social Security Act in the Omnibus Budget Reconciliation Act of 1981. The addition of Section 1915(b) authorized the waiver of statutory requirements that Medicaid programs offer comparable benefits statewide and offer recipients freedom of choice in obtaining services. The amendment also specified that PCCM services would be Medicaid-covered and that qualifying PCCM programs must make provisions for 24-hour emergency treatment and reasonable geographic availability delivery sites as well as have a sufficient number of physicians to serve the Medicaid population promptly and without compromise to the quality of care.

The Balanced Budget Act of 1997 further amended the Social Security Act to include a new Section 1932 state plan option as an alternative to seeking waivers under Section 1915(b) and research and demonstration projects under Section 1115. The new authority permitted states to implement mandatory managed care without waivers and without the cost-neutrality requirements associated with Section 1115. Approval could be obtained through a state plan amendment, and there was no time limit on the approval. The managed-care state plan was also required to offer enrollees in urban areas a choice between at least two managed-care organizations or between a PCCM system and a managed-care organization. In rural areas, there could be one managed-care organization or PCCM as long as there was a choice of physicians or case managers.

Growth of PCCM Programs

By the mid-1980s, states interested in increasing access to healthcare while holding providers accountable and controlling costs began enrolling Medicare recipients in PCCM programs. These programs attempted to reduce inappropriate hospital emergency department use and other types of high-cost care. In many instances, states developed PCCM programs as a stepping stone to risk-based managed care, and these programs grew steadily during the 1990s. When commercial managed-care organizations began declining to serve Medicaid populations in many markets, even those states that originally intended to move all their Medicaid recipients to risk-based managed care began considering PCCM as a viable method for maintaining Medicaid managed-care delivery systems.

Presently, 30 states in the nation use PCCM, and it is the model of choice for rural areas, where a relative scarcity of providers and a scattered population have resulted in weaker managed-care penetration. Due to its flexibility, PCCM is also used in urban areas. It is frequently the default enrollment for Medicaid recipients who fail to make a choice of a plan. Furthermore, PCCM may be used only in specific markets and also statewide, under either voluntary or mandatory conditions. In markets where feasible, states commonly offer both PCCM [Page 959]programs and risk models. The resulting competition increases recipient choice and motivates both managed-care organizations and PCCM programs to improve quality and service. However, states must be careful to apply access, quality, and reporting standards evenly to avoid encouraging managed-care-organizations' withdrawal.

...